An exodus of male physicians from primary care is driving a marked shift
in the U.S. physician workforce toward medical-specialty practice, according
to a national study by the Center for Studying Health System Change (HSC). Two
factors have helped mask the severity of the shift—a growing proportion of female
physicians, who disproportionately choose primary care, and continued reliance
on international medical graduates (IMGs), who now account for nearly a quarter
of all U.S. primary care physicians. Since 1996-97, a 40 percent increase in
the female primary care physician supply has helped to offset a 16 percent decline
in the male primary care physician supply relative to the U.S. population. At
the same time, primary care physicians incomes have lost ground to both inflation
and medical and surgical specialists incomes. And women in primary care face
a 22 percent income gap relative to men, even after accounting for differing
characteristics. If real incomes for primary care physicians continue to decline,
there is a risk that the migration of male physicians will intensify and that
female physicians may begin avoiding primary care—trends that could aggravate
a predicted shortage of primary care physicians.

Workforce Shifts Toward Medical Specialists

hile there is an ongoing debate about the adequacy of the
overall U.S. physician supply, there is general agreement that the existing
physician workforce is not choosing specialties or practice locations in sync
with the nations medical needs.1 Physician-to-population
ratios vary greatly across the country. And in areas with many low-income residents
or rapid population growth, the supply of physicians has not kept pace.2
Among U.S. physicians who work 20 or more hours a week providing direct patient
care, only 37 percent specialize in primary careinternal, family, pediatric
or geriatric medicinea much lower proportion than in other developed countries,
such as the Netherlands, Denmark, the United Kingdom and Spain.3

As the U.S. population ages and many of the 76 million baby boomers develop
multiple chronic conditions, an adequate supply of primary care physicians will
be critical to meet the nations health care needs. Over the last decade, however,
the supply of medical specialists, such as cardiologists and gastroenterologists,
has increased significantly, with concurrent reductions in the supply of both
primary care physicians and surgeons, according to HSCs nationally representative
Community Tracking Study (CTS) Physician Survey (see Data Source).
The proportion of medical specialists grew from 32.2 percent in 1996-97 to 37.6
percent of all patient-care physicians in 2004-05, while the proportion of primary
care physicians decreased from 38.9 percent to 36.7 percent (see Table
1). Likewise, the proportion of surgeons declined from 28.9 percent to 25.7
percent.

Overall, from 1996-97 to 2004-05, there has been a modest increase in the physician
population relative to the general U.S. population (see Supplementary
Table 1). During this time, however, the number of primary care physicians
per capita has fallen slightly, as the number of male primary care physicians
declined substantially, from 39.3 per 100,000 people in 1996-97 to 33.0 per
100,000 in 2004-05. Without the increase in the supply of female primary care
physiciansfrom 12.1 per 100,000 people in 1996-97 to 17.0 per 100,000
in 2004-05a larger reduction in the primary care workforce relative to
the population would have occurred.

Women Shore Up The Primary Care Workforce

he increasing presence of women is one of the most notable
physician workforce trends. Women accounted for a quarter of all patient-care
physicians in 2004-05, up from 18 percent in 1996-97 (see Table
2). Female physicians are much more prevalent in primary caremore
than one in three primary care physicians is a woman, compared with 22 percent
of medical specialists and 17 percent of surgeons. And, among female physicians
in 2004-05, half practiced in primary care, one-third in medical specialties,
and only 17 percent in surgical specialties (see Table 3).

Since the mid-1990s, there has been little change in the distribution of female physicians among the categories of primary care, medical specialties and surgical specialties. Instead, the migration of male physicians toward medical specialties and away from primary care and surgical specialties has largely been responsible for the specialty shifts in the overall physician population. A 40 percent increase in the supply of female primary care physicians helped to offset a 16 percent decrease in the supply of male primary care physicians relative to the U.S. population.

Female physicians are much more likely than their male counterparts to practice
in pediatrics: Nearly one in six female physicians is a pediatrician, compared
with one in 17 male physicians; and women account for about half (49%) of all
pediatricians. Women also are more likely than men to practice in obstetrics-gynecology:
Women make up more than one-third of the obstetrician-gynecologist workforce,
while accounting for only 10 percent of the workforce in other surgical specialties.
Obstetrician-gynecologists are able to meet some of the primary care needs of
healthy women during their childbearing years.4

In patterns that have remained consistent since the mid-1990s, female primary care physicians tend to be younger than their male counterparts (44.2 vs. 50.9 average age in 2004-05) and have correspondingly fewer years in practice (11.6 vs. 18.3 average years), but they are more likely than men to be board-certified (94.4% vs. 88.3%). Over time, the proportion of both male and female primary care physicians with board certification has increased substantially, likely reflecting efforts by physician educational commissions to improve the qualifications of the physician workforce and the increased availability of board certification among various specialties.

Over the past decade, average hours worked on all medically related activities
by primary care physicians have declined53.8 hours a week in 1996-97 vs.
51.4 hours a week in 2004-05.5

Women in primary care worked fewer hours on average than men (46.9 hours vs. 53.6 hours a week in 2004-05), but womens average work hours have held steady over time while mens hours have declined (from 55.7 hours per week in 1996-97), so the gender gap in hours worked has narrowed somewhat. Interestingly, for physicians of both genders, the average hours spent in direct patient care has increased by one hour over this same time period.

Despite this narrowing of the gender gap in average work hours, the fact that female physiciansa growing contingent of the workforcework fewer hours than male physicians needs to be taken into account when physician workforce estimates, including physician-to-population ratios, are calculated. And it is not only women, but also younger physicians in general, who are working fewer hours as they seek more controllable lifestyles. Adequately accounting for these trends is important in improving the accuracy of workforce projections.

IMGs Bolster Primary Care for Now

early one-fourth of the primary care physician workforce
is composed of international medical graduates, whose share of the primary care
workforce has remained stable at just more than 24 percent since 2000-01, after
increasing from 20.7 percent in the late-1990s. Although primary care IMGs tend
to be slightly older than their U.S.-trained counterparts (50.1 vs. 48.1 average
age in 2004-05), they average fewer years in practice (14.8 vs. 16.4 years)
and are less likely to be board-certified (84.4% vs. 92.2%). Primary care IMGs
have historically served in lower-income and medically underserved areas at
rates higher than U.S.-trained primary care physicians,6
thus helping to address some of the gaps in access to care for these populations.

IMGs continue to practice in primary care at higher rates than U.S.-trained physicians (42.0% vs. 35.4% in 2004-05). However, IMGs, like U.S.-trained physicians, have steadily migrated into medical specialties in recent years, leading to a substantial decline in the proportion of IMGs practicing in primary care since 2000-01 (42.0% of IMGs in primary care in 2004-05 vs. 47.1% in 2000-01).

Primary Care Incomes Lag; Women Fare Worst

n 2003, net income for primary care physicians averaged
approximately $146,000an increase of 8.4 percent over 1995 income. After
adjusting for inflation, however, primary care physician net income actually
declined by 10.2 percent over the eight-year period. During that time, medical
specialists, whose baseline incomes were already higher than those of primary
care physicians, kept pace with inflation, while surgeons lost ground8.2
percent net income declinebut remained the highest earning of the three
physician specialty categories.7

On average, female primary care physicians earned about 30 percent less than
their male counterparts in 2003average reported net income of $114,316
vs. $162,934 (see Supplementary Table 2). Male-female income
gaps also were substantial for medical specialists (22.8%) and surgeons (30.8%),
but the primary care gap is particularly relevant since primary care income
levels are substantially lower than those of specialists.

Male-female income gaps persisted even after controlling for personal and practice
characteristics, including specialty, years of experience, board certification,
IMG status, average hours worked, practice setting, proportions of Medicaid
and capitated revenue, and practice ownership status. This finding is consistent
with earlier research.8

However, factors affecting choice of practices that offer more flexible hours or less on-call time, which might translate into income differences for men and women, are not captured in the CTS Physician Survey data. So, the impact of such factors on the income gap cannot be determined.

Adjusted incomes (controlling for personal and practice characteristics) revealed a 22 percent gender gap in 2003 for primary care physiciansa gap that has widened since 1995, when it was 16 percent. In contrast, women in the medical specialties have reduced the income gap considerably relative to their male counterparts.

Policy Implications

emale medical school graduates have traditionally chosen
primary care at much higher rates than men,9 and this has
helped to counteract some of the decline in the proportion of male graduates
pursuing primary care. However, women still constitute a smaller proportion
of the active physician workforce and work fewer hours on average, likely because
of competing child-care responsibilities. Therefore, the increase in female
primary care physicians cannot make up, on a one-to-one basis, for the departure
of men from the field

Primary care also has counted on international medical graduates as a source of new physicians. IMGs, in particular foreign citizens working in the U.S. on temporary visas, still practice in medically underserved areas at higher rates than do U.S.-trained physicians. A continued influx of IMGs, along with the increased presence of women, into primary care may have helped to mask the severity of the trends that are discouraging physicians from choosing primary care careers.

Declining real incomes for primary care physicians, both in absolute terms
and relative to the declines experienced by other physician specialties, have
made careers in primary care less attractive to medical students and residents.10
If real incomes for primary care physicians continue to decline, there is a
risk that the exodus from primary care will accelerate and trigger or aggravate
a workforce shortage. Given that female physicians earn substantially less to
begin with, their continuing commitment to primary care in the face of declining
real incomes is striking, but it is uncertain how long such constancy can be
sustained.

To encourage the right distribution of physicians to meet the nations medical needs, policy makers may need to use Medicare and Medicaid payment rates to realign the price signals being sent to physicians. Primary care physicians, whose incomes tend to be highly dependent on office visits and cognitive services rather than procedures, cannot simply increase the number of procedures or tests that they deliver as a tool to offset stagnant or declining fees the way that some medical specialists can.

Policy makers, recognizing the pressures faced by physicians in specialties
relying on cognitive services, did, in fact, incorporate increased payments
for evaluation and management services as part of the most recent five-year
update of Medicare relative values.11 But the gains for
primary care specialists are projected to be relatively small, in part because
of the failure of the update process to identify many procedural services for
which productivity trends should lead to a decline in relative values. For example,
the most recent relative value update resulted in increases of only 5 percent
for internal medicine and family practice. Moreover, some activities that primary
care physicians are expected to perform, such as care coordination and patient
education, continue as non-reimbursed services (separately from office visits).

Until such imbalances in physician payments are addressed, incomes for primary care physicians are likely to continue falling behind those of medical specialists, and maintaining a primary care physician workforce adequate to meet the needs of the U.S. population will become more challenging.

Data Source

This Tracking Report presents findings from three rounds of the HSC Community
Tracking Study Physician Survey, a nationally representative telephone survey
of physicians involved in direct patient care in the continental United States.
The sample of physicians was drawn from the American Medical Association and
the American Osteopathic Association master files. To participate in the survey,
respondents had to be active, nonfederal, office- or hospital-based physicians
practicing in the 48 contiguous states who spent at least 20 hours a week in
direct patient care. Residents and fellows, as well as radiologists, anesthesiologists
and pathologists, were excluded. The 1996-97 and 2000-01 surveys each contain
information on about 12,000 physicians, while the 2004-05 survey includes responses
from more than 6,600 physicians. The response rates ranged from 52 percent to
65 percent. Physicians were asked to report their incomes for the last full
year prior to the initial fielding of each survey (e.g., respondents to the
1996-97 survey were asked to report their 1995 incomes). As a result, the timeframe
for income estimates differs from the timeframes for other measures.